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Fuhrman &Zimmerman'sPediatric CriticalCare
FIFTH EDITION
BRADLEY P. FUHRMAN, MD, FCCMProfessor and Chair, Department of Pediatrics, Texas Tech University – Paul L. FosterSchool of Medicine, Physician-in-Chief, El Paso Children's Hospital, El Paso, Texas
JERRY J. ZIMMERMAN, MD, PhD, FCCMProfessor of Pediatrics and Anesthesiology, Faculty, Pediatric Critical Care Medicine, SeattleChildren’s Hospital, Harborview Medical Center, University of Washington School ofMedicine, Seattle, Washington
Robert S.B. Clark, MDProfessor and Chief, Pediatric Critical Care Medicine, Medical Director, Brain CareInstitute, Children's Hospital of Pittsburgh of UPMC, Associate Director, Safar Center forResuscitation Research, University of Pittsburgh, School of Medicine, Pittsburgh,Pennsylvania
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Monica Relvas, MD, FAAP, FCCM, MSHAMedical Director, Pediatric Critical Care Medicine, Covenant Women and Children’sHospital, Associate Clinical Professor, Texas Tech University, Lubbock, Texas
Alexandre T. Rotta, MD, FCCMLinsalata Family Chair in Pediatric Critical Care and Emergency Medicine, Chief, Divisionof Pediatric Critical Care Medicine, UH Rainbow Babies and Children's Hospital, Professor,Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland,Ohio
Ann E. Thompson, MD, MHCPMProfessor, Critical Care Medicine, Vice Dean, University of Pittsburgh School of Medicine,Pittsburgh, Pennsylvania
Joseph D. Tobias, MDChief, Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital,Professor of Anesthesiology and Pediatrics, The Ohio State University, Columbus, Ohio
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Table of Contents
Instructions for online access
Cover image
Title Page
Copyright
Contributors
Preface
Section I Pediatric Critical Care: The Discipline
Chapter 1 History of Pediatric Critical Care Medicine*
Evolution of Modern Medicine
Anatomy and Physiology
Resuscitation and Ventilatory Support
Poliomyelitis and Creation of the First Intensive Care Units
Definitions
First Pediatric Intensive Care Units
Central Role of Critical Care Nursing
Role of Pediatric Anesthesiologists and Pediatricians in Founding Pediatric Critical CareMedicine
Growth of Pediatric Critical Care Medicine
Cost of Success in Pediatric Critical Care Medicine
4
Around the World
High-Mortality Countries
Summary
Acknowledgments
References
Chapter 2 High-Reliability Pediatric Intensive Care Unit
Introduction
PICU as System
Models of Critical Care Delivery
Summary
References
Chapter 3 Subspecialization Within Pediatric Critical Care Medicine
Early History
Adult Subspecialization Within Critical Care
Subspecialized Pediatric Intensive Care Units
Cardiac Intensive Care
Neurocritical Care
Adequate “Dose” of Subsubspecialty Training
Impact on Research
References
Chapter 4 Critical Communication in the Pediatric Intensive Care Unit
Intensive Care Unit Design
Medical Record
Huddles
Checklists
Rounds
Closed-Looped Communication
Transitions of Care
5
Medical Training
Debriefing
Team Training
Conclusion
References
Chapter 5 Professionalism in Pediatric Critical Care
The Virtuous Doctor
The Stakes
The Great Paradox of the Medical Profession
Professionalism, the Physician Charter
The PICU as a Site for Medical Education and Lifelong Learning
References
Chapter 6 Nurses in Pediatric Critical Care
Describing What Nurses Do: The Synergy Model
Leadership
Nursing Research
Summary
References
Chapter 7 Research in Pediatric Critical Care
Strengths, Weaknesses, Opportunities, and Threats to Pediatric Critical Care Research
Strengths of Pediatric Critical Care Research
Weaknesses of Pediatric Critical Care Research
Opportunities for Pediatric Critical Care Research
Threats to Pediatric Critical Care Research
Conclusions
References
Chapter 8 Proving the Point
Evidence-Based Medicine Process
6
Study Types
Levels of Evidence
Challenges to Evidence-Based Medicine
Conclusion
References
Chapter 9 Prediction Tools for Short-Term Outcomes Following Critical Illness inChildren
Introduction
Historical Perspective
Methods
Prediction Tools for Assessment of Mortality Risk
Next Generation: Morbidity and Mortality Prediction—Trichotomous Outcome
Future Directions—Prediction Tools for Decision Support
References
Chapter 10 Long-Term Outcomes Following Critical Illness in Children
Mortality Reduction: The First Frontier for Critical Care Medicine
Mitigating Long-Term Morbidity: The Next Frontier for Pediatric Critical Care Medicine
Metrics for Patient-Centered Outcomes: Functional Status and Health-Related Quality ofLife
Novel Approaches to Improving Long-Term Outcomes for PICU Survivors
Conclusions
References
Chapter 11 Safety and Quality Assessment in the Pediatric Intensive Care Unit
Brief Consideration of the Relationship Between Safety and Quality
State of Safety and Quality in Pediatric Intensive Care Units
Fundamentals of Quality Improvement and Patient Safety: Systems Thinking
Fundamentals of Patient Safety With an Introduction to Safety I and Safety II
Patient Safety in the Pediatric Intensive Care Unit: Past, Present, and Future
Conclusions
7
References
Chapter 12 Information Technology in Critical Care
Digital Infrastructure in Health Care
Electronic Health Record
Clinical Decision Support
Patient Safety and Technology in the ICU
Privacy and Security of Health Information
Telemedicine
“Big Data” in Critical Care
Conclusion and Future Directions
Acknowledgments
References
Chapter 13 Building Partnerships
Definition of “Family”
Historical Evolution of Patient- and Family-Centered Care
Fundamental Needs of Patients and Families in the ICU
Core Principles of Patient- and Family-Centered Care,
Patient- and Family-Centered Care Improves Outcomes for All Stakeholders
Overcoming Barriers and Challenges to Patient- and Family-Centered Care in the ICU
Summary
References
Chapter 14 Ethics in Pediatric Intensive Care
Defining Bioethics
Approach to Bioethics Dilemmas in the PICU
Ethics of Patient and Surrogate Decision Making
Other Ethical Issues in the PICU
Goals for the Ethical Practice of the Intensivist
References
8
Chapter 15 Ethical Issues in Death and Dying
Decision Making at the End of Life
Withholding and Withdrawing of Life-Sustaining Treatments
Death Determination
References
Chapter 16 Palliative Care in the Pediatric Intensive Care Unit
Introduction
Palliative Care Consults in the PICU
Epidemiology of Pediatric Death in the PICU
Communication
Limitation of Interventions
Pain and Symptom Management
Practical Aspects of Care at the End of Life
Care of Family and Staff After a Child's Death
References
Chapter 17 Process of Organ Donation and Pediatric Donor Management
Introduction
Role of the Pediatric Intensivist and Critical Care Team in the Process of Organ Donation
Determination of Neurologic Death
Brain Death Physiology
Physiologic Considerations in the Management of the Pediatric Organ Donor
Treatment of Hemodynamic Instability
Hormonal Replacement Therapy
Management of Pulmonary Issues for the Potential Pediatric Organ Donor
Fluid and Electrolyte Disturbances
Diabetes Insipidus
Oliguria
Glucose, Potassium, and Calcium Derangements
Coagulation Abnormalities and Thermoregulatory Instability
9
Medical Examiner/Coroner Issues and Organ Donation for Children
Donation After Circulatory Death
Contraindications to Organ Donation
Evolving Areas of Transplantation
Summary
References
Chapter 18 Pediatric Transport
Adult-Oriented Medical Systems Frequently Fail Children
Components of a Specialized Interfacility Transport Team
Referring Hospital Responsibilities
Summary
References
Chapter 19 Pediatric Vascular Access and Centeses
Intraosseous Infusion
Arterial Catheter Placement
Pericardiocentesis
Umbilical Arterial Catheter and Umbilical Venous Catheter Placement
Central Venous Line Placement
Peripherally Inserted Central Venous Catheters
Thoracentesis and Tube Thoracostomy
Paracentesis
References
Chapter 20 Emerging Role of Ultrasonography in the Pediatric Intensive Care Unit
Ultrasound Physics and Basics of Image Optimization
Procedural Guidance
Drainage Procedures
Lumbar Puncture
Diagnostic Modalities
10
Conclusion
References
Chapter 21 Pediatric Critical Care in Resource-Poor Settings
Child Mortality Rates
Cost of Intensive Care
Ethics of Intensive Care in Resource-Poor Settings
Strengthening Critical Care Infrastructure
Critical Illness During Disease Outbreaks
How to Develop an ICU in Low- to Middle-Income Countries
Importance of Critical Care Research in Limited Resource Settings
References
Chapter 22 Educating the Intensivist
Adult Learning
Requirements
Acknowledgment
References
Chapter 23 Lifelong Learning
Lifelong Learning
Adult Learning Theory
Applying Adult Learning Theory to Medical Education (Learner Assessment DrivesTeaching Methods)
Undergraduate Medical Education
Exploration of Medical School Progression According to Competency by the AmericanAssociation of Medical Colleges With the Education in Pediatrics Across the Continuumand Entrustable Professional Activities Pilots
Graduate Medical Education
Beyond Undergraduate Medical Education and Graduate Medical Education
New Methods of Assessment
Current Controversies, Future Challenges
Conclusions
11
References
Chapter 24 Public Health Emergencies and Emergency Mass Critical Care
Basic Concepts
Pediatric Disaster Timeline
Emergency Department Phase
Intensive Care Unit Phase
PICU Operations in a Gradual-Onset and Sustained Public Health Emergency
Critical Care in Specific Types of Public Health Emergencies
References
Section II Cardiovascular System
Chapter 25 Structure and Function of the Heart
Anatomic Development and Structure
Physiologic Development and Function
Acknowledgment
References
Chapter 26 Regional Peripheral Circulation
General Features
Regional Circulations
Conflicting Needs of Regional Circulations
References
Chapter 27 Endothelium and Endotheliopathy
Normal Endothelial Function
Endothelial Cell Dysfunction
Biomarkers of Endothelial Activation
Conclusions
References
12
Chapter 28 Principles of Invasive Monitoring
Role of Invasive Hemodynamic Monitoring
Indications for Invasive Hemodynamic Measurements
Principles of Measurement
Invasive Techniques
Monitoring Techniques with the Pulmonary Artery Catheter
Catheter Placement
Measurement of Cardiac Output
Calculation of Oxygen Delivery and Consumption
Novel Monitoring Devices
Conclusions
References
Chapter 29 Assessment of Cardiovascular Function
Cardiovascular Function
Quantity of Therapy
Variables That Determine Tissue Oxygenation
Monitoring Tissue Oxygenation
Assessing Variables That Affect the Quantity of Therapy
Physiology of the Patient with a Single Ventricle
References
Chapter 30 Myocardial Dysfunction, Extracorporeal Life Support, and VentricularAssist Devices
Introduction
Pediatric Heart Failure
Mechanical Circulatory Support in Pediatric Patients
Extracorporeal Life Support
Ventricular Assist Devices
Patient Selection and Management
Basic Management of the Ventricular Assist Device Patients
13
Mechanical Circulatory Support and Single Ventricle
Outcomes
Current Perspective and Future Directions
Conclusions
References
Chapter 31 Echocardiographic Imaging
Introduction
Diagnosis of Structural Defects
Ventricular Function
Assessing Volume Status
Measuring Valve Function
Evaluating Pulmonary Hypertension
Assessing Pericardial Effusion
Vascular
Catheter Manipulation
Devices
Cardiovascular Communications and Physiology
Summary
References
Chapter 32 Diagnostic and Therapeutic Cardiac Catheterization
Catheterization Laboratory Environment
Hemodynamic and Oxygen Saturation Data
Assessment of Critical Illness
Transcatheter Radiofrequency Ablation
Congenital Heart Disease
Cardiac Catheterization and Extracorporeal Membrane Oxygenation
Acknowledgment
References
14
Chapter 33 Pharmacology of the Cardiovascular System
Mechanisms of Response
Acknowledgments
References
Chapter 34 Cardiopulmonary Interactions
Effects of Ventilation on Circulation
Effects of Cardiovascular Function on Respiration
References
Chapter 35 Disorders of Cardiac Rhythm
Classification of Arrhythmias
Approach to Diagnosis
Treatment of Rhythm Disturbances
Approach to Therapy
Specific Arrhythmias
References
Chapter 36 Shock States
Definition and Physiology
Recognition and Assessment of the Shock State
Treatment of Shock
Multisystem Effects of Shock
Functional Classification and Common Underlying Etiologies
Obstructive Shock
Distributive Shock
Septic Shock
Summary
References
Chapter 37 Pediatric Cardiopulmonary Bypass
15
Background
Equipment and Preparation for Cardiopulmonary Bypass
Cardiopulmonary Bypass
References
Chapter 38 Critical Care After Surgery for Congenital Cardiac Disease
Introduction
Neonatal Considerations
Preoperative Care
Postoperative Care
Critical Care Management of Selected Specific Lesions
Summary
Acknowledgment
References
Chapter 39 Cardiac Transplantation
Critical Care of the Pediatric Patient Waiting for Heart Transplantation
Management of the Potential Heart Donor
Critical Care Management of the Orthotopic Heart Transplant Recipient
Complications of Immune Suppression in Heart Transplant Recipients Occurring in thePediatric Intensive Care Unit
Future Management Strategies for Critical Care of Infants and Children WithCardiopulmonary Failure
References
Chapter 40 Acute and Chronic Heart Failure
Heart Failure
Definition
Causes of Heart Failure
Physiologic Consideration in the Patient With Heart Failure
Assessment of the Patient With Heart Failure
Diagnostic Studies in Patients With Heart Failure
16
Management of Low Cardiac Output Syndrome
Pharmacology of Heart Failure
Mechanical Circulatory Support
Heart Transplantation
Conclusion
References
Chapter 41 Physiologic Foundations of Cardiopulmonary Resuscitation
Mechanisms of Blood Flow
Newer Cardiopulmonary Resuscitation Techniques
Pharmacology
Vasopressin
Management of Ventricular Fibrillation
Future Directions
References
Chapter 42 Performance of Cardiopulmonary Resuscitation in Infants and Children
Four Phases of Cardiac Arrest
Epidemiology of Pediatric Cardiac Arrest
Interventions During the Low-Flow Phase: Cardiopulmonary Resuscitation
Medications Used to Treat Cardiac Arrest
Postresuscitation Myocardial Dysfunction
Other Considerations
Ventricular Fibrillation and Ventricular Tachycardia in Children
Summary
References
Section III Respiratory System
Chapter 43 Structure and Development of the Upper Respiratory System in Infantsand Children
17
Developmental Anatomy of the Upper Airway
Anatomy and Physiology of the Upper Airway
Acknowledgment
Key References
Chapter 44 Structure and Development of the Lower Respiratory System in Infantsand Children
Lower Respiratory System
Lung Circulation
Summary
Acknowledgments
References
Chapter 45 Physiology of the Respiratory System
Physiology of the Respiratory System
Flow Resistance of the Respiratory System
Dynamic Change in Airway Caliber During Respiration
Applied Forces
Interactions Between Lungs and Chest Wall
Time Constant of Emptying
Physiology of Positive Pressure Mechanical Ventilation
Gas Exchange
Alveolar Ventilation
References
Chapter 46 Noninvasive Respiratory Monitoring and Assessment of Gas Exchange
Pulse Oximetry
Principles of Pulse Oximetry
Validation
Sources of Error
Probe Placement
Capnometry and Capnography
18
Physiologic Basis
Clinical Applications
Operating Principles of Capnometry
Differential Diagnosis of Abnormal Capnograms
Transcutaneous Monitoring
Oxygen Monitoring
Carbon Dioxide Monitoring
Conclusion
References
Chapter 47 Overview of Breathing Failure
Physiology of Breathing
Controls of Breathing
Breathing Failure
Breathing Failure From Lung Disease
Conclusion
References
Chapter 48 Ventilation/Perfusion Inequality
Distribution of Ventilation
Distribution of Perfusion
Fractal Model of Pulmonary Blood Flow and Ventilation
Fractal Model of the Pulmonary Ventilation
VA/Q Abnormalities in Pulmonary Disease
Therapeutic Considerations
References
Chapter 49 Mechanical Dysfunction of the Respiratory System
Work, Power, and Energy Expenditure in the Respiratory System
Determinants of Respiratory Work
Nondissipative Phenomena: Elastic Behavior of the Respiratory System
19
Dissipative Phenomena: Resistive Behavior of the Respiratory System
Determinants of Regional Gas Flow Distribution in the Lungs
Restrictive and Obstructive Respiratory Disease
Determinants of Respiratory Efficiency
Conclusion
References
Chapter 50 Specific Diseases of the Respiratory System
Initial Management
Congenital Malformations
Laryngomalacia
Laryngeal Webs, Stenosis, and Tumors
Vascular Impingement on the Trachea
Bronchomalacia and Intrathoracic Tracheomalacia
Infectious Processes
Laryngotracheobronchitis
Epiglottitis
Peritonsillar Abscess
Retropharyngeal Abscess
Bacterial Tracheitis
Laryngeal Papillomatosis
Vocal Cord Paralysis
Intrathoracic Mass Lesions Causing Respiratory Obstruction
Trauma
Laryngotracheal (Subglottic) Stenosis
Foreign Body Aspiration
Traumatic Injury to the Airway
Burn Injury to the Upper Airway
Angioedema
Tracheostomy
Postoperative Nursing Care
20
Complications
Decannulation
References
Chapter 51 Pediatric Acute Respiratory Distress Syndrome
Introduction
Clinical Features: Pathophysiology
Definition
Pathobiology
Ventilator Management
Pulmonary Ancillary Therapies
Nonpulmonary Therapies
Noninvasive Support
Extracorporeal Life Support
Morbidity and Outcomes
References
Chapter 52 Ventilator-Induced Lung Injury
Evidence for Ventilator-Induced Lung Injury
Roles of Tidal Volume, Positive End-Expiratory Pressure, and Overall Lung Distention
Possible Mechanisms of Ventilator-Induced Lung Injury
New Insights in Ventilator-Induced Lung Injury
Strategies to Reduce Ventilator-Induced Lung Injury: Use of the Pressure-Volume Curveand Analysis of the Mechanics of the Respiratory System
Strategies to Reduce Ventilator-Induced Lung Injury: Mechanical Measures
Conclusion and Clinical Applications
References
Chapter 53 Asthma
Epidemiology and Risk Factors
Pathophysiology
Clinical Assessment
21
Laboratory Data
Electrocardiography
Spirometry
Treatment
Management in the Intensive Care Unit
Mechanical Ventilation
Antibiotics
Bronchoscopy
Extracorporeal Life Support
Prognosis
References
Chapter 54 Neonatal Respiratory Disease
Lung Maturation and Physiologic Changes at Birth
Acute or Early-Onset Respiratory Disorders
Congenital Malformations of the Lung
Special Treatment Considerations for Acute Respiratory Failure
Chronic Pulmonary Disease
Nonpulmonary Conditions That Result in Respiratory Disease
Metabolic Disorders
References
Chapter 55 Pneumonitis and Interstitial Disease
Pathogenesis
Pathophysiology
Diagnosis
Bacterial Pneumonitis
Viral Pneumonitis
Fungal Pneumonitis
Primary Pulmonary Fungi
Opportunistic Pulmonary Mycoses
22
Pneumocystis carinii Pneumonia
Chemical Pneumonitis
Idiopathic Interstitial Lung Disease
Pediatric Pulmonary Hemorrhage
Summary
References
Chapter 56 Diseases of Pulmonary Circulation
Etiology and Treatment of Pulmonary Hypertension
Transitional Circulation
Persistent Pulmonary Hypertension of the Newborn
Management of iNO-Resistant PPHN
Prostaglandin E1 (PGE1)
Conclusions
References
Chapter 57 Mechanical Ventilation and Respiratory Care
Introduction
Applied Respiratory Physiology
Indications for Mechanical Ventilation
Design and Functional Characteristics of Ventilators
Modes of Ventilation
Ventilation for Selected Underlying Pathophysiology
Patient-Ventilator Asynchrony
High-Frequency Ventilation
Adverse Effects of Mechanical Ventilation
Specialty Gases
Respiratory Care During Mechanical Ventilation
Weaning From Mechanical Ventilation
Home Respiratory Care
References
23
Chapter 58 Noninvasive Ventilation
Introduction
Historical Perspective
Indications
Short-Term Noninvasive Ventilation
Adult Studies on the Short-Term Use of Noninvasive Ventilation
Pediatric and Neonatal Studies
Acute Short-Term Indications
Long-Term Noninvasive Ventilation
Physiologic Effects and Outcomes of Long-Term Noninvasive Ventilation
Interfaces
Equipment
Optimizing Patient-Ventilator Interaction
Ventilator Settings
Complications and Concerns During Short-Term Noninvasive Ventilation
Circuit and CO2 Rebreathing
Negative Pressure Ventilation
Summary
References
Chapter 59 Extracorporeal Life Support
Materials and Methods
Patient Populations Treated With Extracorporeal Life Support
Patient Selection Criteria
Physiology of Extracorporeal Life Support: Gas Exchange and Oxygen Delivery
Patient Management
Weaning From Extracorporeal Membrane Oxygenation
Complications
The Future
References
24
Section IV Central Nervous System
Chapter 60 Structure, Function, and Development of the Nervous System
Major Cell Types
Intercellular Communication in the Nervous System
Neurotransmitter Systems
Major Anatomic Organization of the Nervous System
Blood-Brain Barrier
Ventricles and Cerebrospinal Fluid
Vasculature in the Central Nervous System
Emerging Characterization of the “Lymphatic” Circulation in the CNS
Developmental Processes Relevant to Pediatric Critical Care Medicine
New Insights in Neurodevelopment Relevant to Pediatric Critical Care
Conclusion
References
Chapter 61 Brain Malformations
Hydrocephalus
Arachnoid Cysts
Chiari Malformations
Dandy-Walker Malformation
Encephalocele and Meningocele
Spinal Dysraphism
References
Chapter 62 Neurologic Assessment and Monitoring
Overview and Basic Principles of Pediatric Critical Care Neurology
Goals of the Neurologic Examination in the Pediatric Intensive Care Unit
Neuroimaging
Integrating Neurologic Monitoring Data
References
25
Chapter 63 Neuroimaging
Imaging Modality Overview
Preterm and Term Neonate Imaging
Stroke in the Older Infant/Child
Vascular Malformations
Central Nervous System Infection
Demyelinating Disease
Trauma
Hydrocephalus
Tumor
Seizures
Conclusion
References
Chapter 64 Pediatric Neurocritical Care
Historical Context
Rationales for Development of Pediatric Neurocritical Care
Challenges, Controversies, and the Scope of Pediatric Neurocritical Care
Future of Pediatric Neurocritical Care
References
Chapter 65 Coma and Depressed Sensorium
Pathophysiology
Anatomy of Arousal and Ascending Reticular Activating System
States of Impaired Sensorium
Identification of Cause
Initial Assessment and Immediate Resuscitation
Focused Neurologic Examination
Respiratory Pattern
Eye Examination
Motor Examination
26
Focal Neurologic Lesions Could Be Supratentorial or Subtentorial
Presentation of Nonfocal Neurologic Lesions
Herniation Syndromes
Diagnostic Evaluation
Therapeutic Intervention
Outcome
Ethical Considerations
References
Chapter 66 Intracranial Hypertension and Brain Monitoring
Clinical Background
Physiology of the Intracranial Vault
Measurement of Intracranial Pressure
Analysis of Intracranial Pressure
Invasive Intracranial Pressure Monitoring in Clinical Care
Clinical Utility of Intracranial Pressure Monitoring With Other Monitoring Modalities
Monitoring and the Postinsult Natural History
Newer Modalities Supplementing Monitoring of Intracranial Pressure
References
Chapter 67 Status Epilepticus
Proportional Incidences for Symptomatic Epilepsies According to Age and Etiology
Seizure Types and Classification
Seizures Commonly Encountered in the Pediatric Intensive Care Unit
Posttraumatic Epilepsy
Pharmacotherapy
Refractory Status Epilepticus
Surgical Options
Morbidity and Mortality
Acknowledgment
References
27
Chapter 68 Hypoxic-Ischemic Encephalopathy
Epidemiology
Cellular and Molecular Pathobiology
Clinical Pathophysiology
Clinical Outcome After Pediatric Cardiac Arrest
Response of the Immature Brain to Cardiac Arrest
Treatment of Cardiac Arrest
Current and Novel Therapies
Futuristic Approaches
Summary
Acknowledgment
References
Chapter 69 Pediatric Stroke and Intracerebral Hemorrhage
Significance
Arterial Ischemic Stroke
Etiologies and Risk Factors
Pathophysiology
Presentation
Neuroimaging
Laboratory Evaluation
Treatment
Cerebral Sinus Venous Thrombosis
Spontaneous Intracranial Hemorrhage
General Care of the Child With Intracerebral Hemorrhage
Prognosis
Conclusion
References
Chapter 70 Central Nervous System Infections and Related Conditions
Introduction
28
Bacterial Meningitis
Clinical Manifestations
Subdural Empyema
Brain Abscesses
Viral Meningoencephalitis
Conclusion
References
Chapter 71 Acute Neuromuscular Diseases and Disorders
Guillain-Barré Syndrome
Myasthenia Gravis
Congenital and Transient Neonatal Myasthenia Gravis
Tick Paralysis
Periodic Paralyses
Hypokalemic Periodic Paralysis
Hyperkalemic Periodic Paralysis
Botulism
Diphtheria
Acute Intermittent Porphyria
Spinal Muscular Atrophy
Poliomyelitis
Polio-Like Syndromes
Organophosphate and Carbamate Poisoning
References
Section V Renal, Fluids, Electrolytes
Chapter 72 Renal Structure and Function
Renal Development
Renal Anatomy
Renal Vasculature
29
Nephron Unit
Tubular Anatomy
Summary
References
Chapter 73 Fluid and Electrolyte Issues in Pediatric Critical Illness
Overview
Sodium
Hyponatremia
Potassium
Hypokalemia
Hyperkalemia
Magnesium
Hypomagnesemia
Hypermagnesemia
Calcium
Hypocalcemia
Hypercalcemia
Hypophosphatemia
Hyperphosphatemia
References
Chapter 74 Tests of Kidney Function in Children
Assessment of Glomerular Function and Injury
Renal Clearance Techniques
Plasma Disappearance Techniques
Renal Inulin Clearance Compared With Other GFR Measurement Techniques
Plasma Markers
Estimating Equations
Neonatal Renal Function
Other Novel Biomarkers of Acute Kidney Injury Under Investigation
30
Tubular Function
References
Chapter 75 Glomerulotubular Dysfunction and Acute Kidney Injury
Acute Kidney Injury Pathophysiology
Classification of Acute Glomerulotubular Dysfunction
Treatment of Acute Kidney Injury
Acute Kidney Injury: Clinical Impact
Specific Kidney Diseases That May Lead to Acute Kidney Injury
Conclusions
References
Chapter 76 Acid-Base Disorders
Overview of Acid-Base Physiology
Tools for Interpreting Acid-Base Disorders
Conceptual and Practical Integration of the Tools for Assessing Acid-Base Balance
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acid-Base Derangements
Mixed Acid-Base Derangements
Acid-Base Balance in Special Situations: Hypothermia
Summary
References
Chapter 77 Renal Pharmacology
Kidney Function and Drug Disposition
Drug Dosing in Kidney Disease
Kidney as a Therapeutic Target: Diuretics
Prevention/Reversal of Acute Renal Failure
References
Chapter 78 Pediatric Renal Replacement Therapy in the Intensive Care Unit
31
Basic Physiology of Dialysis and Ultrafiltration
Peritoneal Dialysis
Intermittent Hemodialysis
Continuous Renal Replacement Therapy
Outcomes of Renal Replacement in Critically Ill Children
Advances in Pediatric Renal Replacement Therapies
Summary
References
Chapter 79 Acute Severe Hypertension
Introduction
Terminology
Etiology
Pathophysiology
Endothelial Homeostasis
Sympathetic Nervous System Activation
Renin-Angiotensin-Aldosterone System
Nitric Oxide
Volume Overload
Clinical Presentation
Blood Pressure Measurement and Other Monitoring
Pharmacologic Therapy
Special Situations
Summary
Acknowledgment
References
Section VI Metabolism, Endocrinology, and Nutrition
Chapter 80 Cellular Respiration
Pathways of Cellular Respiration
32
Impaired Cellular Respiration in Critical Illness
Clinical Assessment of Oxygen Utilization
Lactate
Venous Oxygen Saturation
Microdialysis
Near-Infrared Spectroscopy
Optical Spectroscopy
Tissue Oxygen Tension
NADH Fluorometry
Magnetic Resonance Spectroscopy
Blood Mitochondrial DNA
Mitochondrial- and Bioenergetic-Targeted Therapy in Critical Illness
Antioxidants
Nitric Oxide Synthase Inhibitors
Glycemic Control
Substrate Provision
Mitochondrial Biogenesis and Mitophagy
Membrane Stabilizers
Hibernation
Conclusions
References
Chapter 81 Biology of the Stress Response
Introduction
Definitions and Historical Perspectives
Stress System Primary Elements
Stress Response
Stress Response in Critical Illness
Recommendations and Conclusions
References
33
Chapter 82 Inborn Errors of Metabolism
Pathophysiology of Inborn Errors of Metabolism
Inheritance of Inborn Errors of Metabolism
Signs and Symptoms of Inborn Errors of Metabolism
Laboratory Evaluation of Suspected Inborn Errors of Metabolism
Postmortem Evaluation of a Child With Suspected Inborn Errors of Metabolism
Emergency Treatment of Children With Suspected Inborn Errors of Metabolism
Classification of Inborn Errors of Metabolism by Clinical Presentation
Metabolic Acidosis
Hypoglycemia
Cardiomyopathy and Inborn Errors of Metabolism
Metabolic Myopathies and Rhabdomyolysis
Neonatal Screening
Conclusion
References
Chapter 83 Genetic Variation in Health and Disease
Introduction
Sequence Variation in Health and Disease
Scale of Mutational Event
Genetic Variation and Protein Synthesis
Developmental Timing of Mutations and Consequences
Genetic Variation in Mendelian and Complex Traits
High-Throughput Technologies—the Good and the Bad
Genome-Wide Association Studies
Looking Toward the Future
References
Chapter 84 Molecular Foundations of Cellular Injury
Cell Death
Mechanisms of Cell Death
34
How Do Cellular Death Mechanisms Propagate Critical Illness?
References
Chapter 85 Common Endocrinopathies in the Pediatric Intensive Care Unit
Hypothalamic-Pituitary-Adrenal Axis
Cortisol Biochemistry
Actions of Cortisol
Assessing the Cortisol Stress Response
Adrenal Insufficiency in the Intensive Care Unit
Corticosteroid Side Effects
Alterations of Glucose Homeostasis
Hyperglycemia
Glucose Measurement
Future Directions
Hypoglycemia
Alterations of Thyroid Hormone in Critical Illness
Acknowledgment
References
Chapter 86 Diabetic Ketoacidosis
Etiology, Definition, and Presentation
Epidemiology
References
Chapter 87 Nutrition in the Critically Ill Child
Introduction
Malnutrition in the Pediatric Critically Ill Patient
Assessment of Nutritional Status
Body Composition
Biochemical Assessment
Underfeeding and Overfeeding in the Pediatric Intensive Care Unit
35
Lipid Requirements
Micronutrient Requirements
Refeeding Syndrome
Enteral Nutrition in Critically Ill Children
Immune-Enhancing Diets for the Critically Ill Child
Parenteral Nutrition
Nutritional Support of Obese Critically Ill Children
Guidelines for Pediatric Critical Care Nutrition
Conclusions
References
Section VII Hematology-Oncology
Chapter 88 Structure and Function of Hematopoietic Organs
Structure and Function of the Bone Marrow
Hematopoiesis
Lymphopoiesis
References
Chapter 89 Erythron in Critical Illness
Introduction
Oxygen Transport
Carbon Dioxide Transport
Biophysical Factors Influencing Gas Transport
Regulation of Blood Flow Distribution by Red Blood Cells
Energy Metabolism in Red Blood Cells
Acquired Red Blood Cell Injury, Eryptosis, and Clearance
Blood Flow Disruption During Critical Illness by Maladaptive Red Blood Cell–BasedSignaling
References
36
Chapter 90 Hemoglobinopathies
Perspective
Globin Gene Loci
Sickle Cell Disease
Thalassemia
References
Chapter 91 Coagulation and Coagulopathy in Critical Illness
Introduction
Overview of Hemostasis
Approach to the Patient With an Actual or Suspected Coagulation Disorder
Potentially Serious Acquired Bleeding Disorders
Iatrogenic Coagulopathy
Platelet Disorders
Selected Disorders
References
Chapter 92 Thrombosis in Pediatric Intensive Care
Developmental Hemostasis
Etiology and Epidemiology
Clinical Features
Diagnosis
Management
Thromboprophylaxis in the Pediatric Intensive Care Unit
Conclusions
Acknowledgment
References
Chapter 93 Transfusion Medicine in the Pediatric Intensive Care Unit
Red Blood Cells
Red Blood Cell Transfusion: Why and Why Not
37
Transfusion of Red Blood Cells: Indications (When)
Types of Packed Red Blood Cell Products
Transfusion of Red Blood Cells: How
Plasma
Platelets
Cryoprecipitate
Transfusions Reactions and Complications
Conclusion
References
Chapter 94 Hematology and Oncology Problems in the Intensive Care Unit
Hematologic Emergencies
Oncologic Emergencies
References
Chapter 95 Critical Illness Involving Children Undergoing Hematopoietic CellTransplantation
Overview
Sources of Hematopoietic Progenitor Cells and Identification of Donors
Indications and Outcomes
Transplant Procedure
Nutritional Support in the Critically Ill Hematopoietic Progenitor Cell TransplantationPatient
References
Section VIII Gastrointestinal System
Chapter 96 Gastrointestinal Structure and Function
Introduction
Intestinal Structure, Digestion, Absorption of Nutrients, Water, and Electrolytes
Water and Solute Transport Across Intestinal Epithelium
Pancreas
38
Hepatobiliary System
References
Chapter 97 Disorders and Diseases of the Gastrointestinal Tract and Liver
Gastrointestinal Evaluation of the Critically Ill Child
Life-Threatening Complications of Gastrointestinal Disorders
References
Chapter 98 Applications of Gastrointestinal Pharmacology
Stress Ulcer Prophylaxis
Mechanism of Stress-Related Mucosal Damage
Epidemiology and Risk Factors for Stress Ulceration
Options for Stress Ulcer Prophylaxis
Infectious Complications of Stress Ulcer Prophylaxis
Histamine-2 Receptor Antagonists
Proton Pump Inhibitors
Gastrointestinal Hemorrhage
Antibiotic-Associated Diarrhea
Rectal Administration of Medication
Nausea and Vomiting
Acknowlegment
References
Chapter 99 Acute Liver Failure, Liver Transplantation, and Extracorporeal LiverSupport
Introduction
Acute Liver Failure
Liver Transplantation
References
Chapter 100 Acute Abdomen
Anatomic and Physiologic Considerations
39
Physical Exam of the Abdomen
Laboratory Tests
Imaging Options
Abdominal Conditions Requiring Treatment in the Intensive Care Unit
Other Specific Conditions
Abdominal Compartment Syndrome
Intraabdominal Abscess
Intestine as a Source of Sepsis
References
Section IX Immunity and Infection
Chapter 101 Innate Immune System
Regulation of the Innate Immune Response
Clinical Manifestations of the Innate Immune Response in the Intensive Care Unit
Therapeutic Targets of the Innate Immune System
Therapeutic Questions Arising From the Innate Immune System
Conclusion
References
Chapter 102 Adaptive Immunity
Introduction
Lymphocytes Develop to Recognize Specific Antigens
B-Cell Activation Leads to Antibody Secretion: The Humoral Immune Response
Effector T Cells Direct Cell-Mediated Immunity
Additional T-Cell Subtypes
Adaptive Immunity in the Intensive Care Unit
Summary
References
Chapter 103 Congenital Immunodeficiency
40
Introduction
Basic Framework for Understanding the Immune System
Specific Disorders Likely to Be Encountered in Pediatric ICU
Radiation Sensitive Disorders: Ataxia Telangiectasia and Nijmegen Breakage Syndrome
Laboratory Evaluation of the Immune System
Treatment of Immune System Disorders
References
Chapter 104 Acquired Immune Dysfunction
Immune Function and Critical Illness
Malnutrition and Immune Function
Transfusions
Immunosuppressive Medications
Uremia
Infectious Agents Other Than HIV
HIV Infection and AIDS
Pulmonary Complications and Respiratory Failure
Upper Airway Obstruction
Cardiovascular Complications
Renal Failure
Abdominal Complications
Hematologic Complications
Malignancies
Neurologic Complications
Infections of CNS
Occupational HIV Exposure
Summary
References
Chapter 105 Immune Balance in Critical Illness
Introduction
41
Innate and Adaptive Immunity
Proinflammatory and Antiinflammatory Responses
CARS and Clinical Outcomes
Immune Modulation in Pediatric ICU
Immune Monitoring in ICU
Conclusion
References
Chapter 106 Pediatric Rheumatic Disease
Rheumatic Diseases: Clinical Presentation, Diagnosis, and Treatment
Rheumatic Diseases: Conditions and Complications in the ICU
Macrophage Activation Syndrome
Central Nervous System Involvement
Complications of the Treatment of Rheumatic Diseases
Summary
Acknowledgments
References
Chapter 107 Bacterial and Fungal Infections, Antimicrobials, and AntimicrobialResistance
General Considerations for Antibiotic Therapy
Antibiotic Classes
Antibiotic Resistance
Antibiotic Resistance and Infections in the Pediatric Intensive Care Unit
Antimicrobial Stewardship
Summary
References
Chapter 108 Life-Threatening Viral Diseases and Their Treatment
Myocarditis
Acute Liver Failure
Viral Pneumonia/Pneumonitis
42
Central Nervous System Infections
Exotic Viral Diseases
Diagnosing Viral Disease
Treatment for Viral Infections
References
Chapter 109 Infectious Syndromes in the Pediatric Intensive Care Unit
Meningococcal Infection
Toxic Shock Syndrome
Necrotizing Fasciitis
Invasive Pneumococcus
Rocky Mountain Spotted Fever
Hantavirus
Acknowledgments
References
Chapter 110 Hospital-Acquired Infection in the Pediatric Intensive Care Unit
Burden of Illness and Scope of the Problem
Epidemiologic Principles of Infection Prevention and Control
Infection Prevention and Control Measures
Specific Health Care−Associated Infection Syndromes in the Pediatric Intensive Care Unit
Acknowledgments
References
Chapter 111 Sepsis
Introduction
Epidemiology
Definitions
Clinical Presentation
Pathogenesis
Genomic Medicine and Sepsis
43
Treatment Strategies
Case for More Effective Stratification in Pediatric Septic Shock
Concluding Perspectives
References
Chapter 112 Multiple Organ Dysfunction/Failure Syndrome in Children
Introduction
Inflammation/Coagulation/Immune Dysfunction/Dysregulated Metabolism Hypothesis
Definitions and Scoring
Outcomes
MOF/MODS Phenotypes, Respective Biomarkers, and Therapies (Table 112.1)
Therapeutic Approaches to SIRS/Sepsis/ALI/MOF (Table 112.2)
Time Course of SIRS/Sepsis-Induced MODS/MOF
Summary
References
Section X Environmental Hazards
Chapter 113 Bites and Stings
Snakebites
Widow Spider Bites
Hymenoptera Stings (Bees, Wasps, and Ants)
References
Chapter 114 Heat Injury
Definitions
Epidemiology
Pathophysiology and Pathogenesis of Heat-Related Illnesses
Systemic Clinical Features
Treatment
References
44
Chapter 115 Accidental Hypothermia
Physiology
Central Nervous System
Cardiovascular
Respiratory
Renal
Coagulation
Treatment
Outcome
References
Chapter 116 Drowning
Definitions
Epidemiology
Pathophysiologic Considerations
Management
Prognosis
References
Chapter 117 Burn and Inhalation Injuries
Types of Burn Injuries
Depth and Extent of the Burn Injury
Early Management of Burn Injuries
Inhalational Injury
Nutritional Support in Burn Patients
Wound Care
Acknowledgment
References
Section XI Pediatric Trauma
45
Chapter 118 Evaluation, Stabilization, and Initial Management After MultipleTrauma
Prehospital Care and Trauma Team Activation
Trauma Resuscitation
Primary Survey
Secondary Survey
Diagnostic Assessment
Emergency Department Thoracotomy
Stabilization and Definitive Care
Conclusions
Acknowledgments
References
Chapter 119 Severe Traumatic Brain Injury in Infants and Children
Epidemiology
Pathophysiology
History
Signs and Symptoms
Initial Resuscitation
Diagnostic Studies and Monitoring Modalities
Treatment in the Pediatric Intensive Care Unit
Miscellaneous
Linking Rehabilitation and Acute Care
Outcomes
Conclusion
References
Chapter 120 Thoracic Injuries in Children
Epidemiology and Prevention
Anatomic and Physiologic Considerations
Initial Resuscitation and Diagnosis
46
Chest Wall Injury
Lung and Airway Injury
Traumatic Asphyxia
Cardiac Injuries
Esophageal Injury
Chylothorax
Diaphragmatic Injury
Conclusions
References
Chapter 121 Abdominal Trauma in Pediatric Critical Care
Mechanisms and Patterns of Injury
Evaluation and Resuscitation
Management of Specific Abdominal Injuries
Acknowledgment
References
Chapter 122 Child Abuse
Recognition of Child Abuse
Skeletal Survey
Abusive Head Trauma
Shaken Baby Syndrome
Inflicted Abdominal and Thoracic Trauma
Sexual Abuse
Protocol for the Medical Investigation of Child Abuse
Fatal Child Abuse
Documentation and Testifying in Court
References
Chapter 123 Violence-Associated Injury Among Children
Physical-Related Injuries in Children
47
Psychologic Injury and Psychosocial and Behavior–Related Effects
Challenges for Follow-Up and Opportunities for a Teachable Moment
References
Section XII Pharmacology and Toxicology
Chapter 124 Principles of Drug Disposition in the Critically Ill Child
Drug Disposition in Infants and Children
Determinants of Effective Therapy
Pharmacokinetic Principles
Critical Care Therapeutics
References
Chapter 125 Molecular Mechanisms of Drug Actions
Targets for Drug Action
Receptor Type and Regulation
Signal Transduction Mechanisms: Intracellular Messengers and Effectors
Multiple Drug Targets Within an Organ System: The Myocardium
Drug Response and Genetic Polymorphisms
Drug Response and Development
Drug Response and Disease
Conclusion
References
Chapter 126 Adverse Drug Reactions and Drug-Drug Interactions
Adverse Drug Reactions by Organ System
Drug-Drug Interactions
References
Chapter 127 Principles of Toxin Assessment and Screening
Common Agents Involved in Serious Pediatric Poisonings
48
Resources for the Clinician
General Assessment of the Poisoned Patient
Summary
Additional Readings
References
Chapter 128 Toxidromes and Their Treatment
Opioids
Sedative Hypnotics
Sympathomimetic Agents
Anticholinergic Agents
Cholinergic Agents
Methemoglobinemia
Xenobiotic-Induced Hyperthermia
Metabolic Acidosis With Increased Anion Gap
Acetaminophen (Paracetamol)
References
Section XIII Anesthesia Principles for the Pediatric IntensiveCare Unit
Chapter 129 Airway Management
Anatomic Considerations
Basic Airway Management
Establishing a Functional Airway
Endotracheal Intubation
Special Circumstances
Alternative Approaches to the Airway
References
Chapter 130 Anesthesia Effects and Organ System Considerations
49
Effects of Anesthetic Agents
Local Anesthetic Agents
Neurologic Injury
Intracranial Pressure
Regulation of Cerebral Blood Flow
Effects of Anesthetics on Cerebral Blood Flow
Anesthesia Neurotoxicity in the Developing Brain
References
Chapter 131 Anesthesia Principles and Operating Room Anesthesia Regimens
Introduction
Preoperative Evaluation
NPO Guidelines
Preoperative Medication
Monitoring
Pharmacology of Anesthetic Agents
Intraoperative Anesthetic Care
Postoperative Care
Conclusions
References
Chapter 132 Malignant Hyperthermia
Pathophysiology
Genetics
Clinical Recognition of a Malignant Hyperthermia Episode in Humans
Treatment of an Episode of Malignant Hyperthermia
Course of a Clinical Episode of Malignant Hyperthermia
Evaluation of Patients at Risk
Testing for Malignant Hyperthermia Susceptibility
Neuroleptic Malignant Syndrome and Serotonin Syndrome
Malignant Hyperthermia Association
50
References
Chapter 133 Neuromuscular Blocking Agents
Introduction
Neuromuscular Junction
Neuromuscular Blocking Agents: Depolarizing Agents
Summary: Neuromuscular Blocking Agents in the PICU
References
Chapter 134 Sedation and Analgesia
Opioids and Analgesia in the Pediatric Intensive Care Unit
Specific Opioid Agonists
Opiate Antagonists
Opiate Tolerance
Benzodiazepines
Specific Benzodiazepines
Flumazenil
Chloral Hydrate
Other Agents for Sedation of the Pediatric Intensive Care Unit Patient
Neuroleptic Malignant Syndrome
Baclofen
Cannabis
Dexmedetomidine
Propofol
Sedation and Analgesia for Procedures
Specific Drugs for Sedation
Sedation-Related Complications
Apoptosis
Pharmacoeconomics
References
51
Chapter 135 Tolerance, Withdrawal, and Dependency
Introduction
History of Tolerance and Withdrawal in the Intensive Care Unit Setting
Clinical Signs and Symptoms of Withdrawal
Treatment of Withdrawal and Clinical Scoring Systems
Summary
References
Chapter 136 Pediatric Delirium
Introduction
Background
Etiology
Epidemiology
Risk Factors
Clinical Presentation
Diagnosis
Treatment
Underlying Illness
Iatrogenic Factors
Environment
Pharmacotherapy
Prevention
Conclusion
References
Section XIV
Board Review Questions
Reference
References
52
Reference
Reference
Reference
Reference
References
Reference
Index
53
Copyright
1600 John F. Kennedy Blvd.Ste 1800Philadelphia, PA 19103-2899
PEDIATRIC CRITICAL CARE, FIFTH EDITIONISBN: 978-0-323-37839-0Copyright © 2017 by Elsevier, Inc. All rights reserved.
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NoticesKnowledge and best practice in this field are constantly changing. As new researchand experience broaden our understanding, changes in research methods,professional practices, or medical treatment may become necessary.Practitioners and researchers must always rely on their own experience andknowledge in evaluating and using any information, methods, compounds, orexperiments described herein. In using such information or methods they should bemindful of their own safety and the safety of others, including parties for whom theyhave a professional responsibility.With respect to any drug or pharmaceutical products identified, readers are advisedto check the most current information provided (i) on procedures featured or (ii) bythe manufacturer of each product to be administered, to verify the recommendeddose or formula, the method and duration of administration, and contraindications.It is the responsibility of practitioners, relying on their own experience andknowledge of their patients, to make diagnoses, to determine dosages and the besttreatment for each individual patient, and to take all appropriate safety precautions.To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
54
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Library of Congress Cataloging-in-Publication Data
Names: Fuhrman, Bradley P., editor.Title: Pediatric critical care / [edited by] Bradley P. Fuhrman, Jerry J. Zimmerman,Joseph A. Carcillo, Robert S.B. Clark, Monica Relvas, Alexandre T. Rotta, Ann E.Thompson, Joseph D. Tobias.Other titles: Pediatric critical care (Fuhrman)Description: Fifth edition. | Philadelphia, PA : Elsevier, [2017] | Includesbibliographical references and index.Identifiers: LCCN 2016034617 | ISBN 9780323378390 (hardcover : alk. paper)Subjects: | MESH: Critical Care | Child | InfantClassification: LCC RJ370 | NLM WS 366 | DDC 618.92/0028—dc23 LC recordavailable at https://lccn.loc.gov/2016034617
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Figures from left to right:Schematic depiction of gram-negative bacteremia.Schematic depiction of Toll-like receptor 4, an element of innate immunity that bindslipopolysaccharide of the gram-negative cell wall (endotoxin), initiating a cascade ofintracellular signaling to promote a proinflammatory host response.Host mRNA expression of the most affected genes in a child with bacterial sepsis.Red, upregulation; blue, downregulation. Courtesy, Hector Wong.Alterations in microvascular flow and effective capillary density of the buccalmucosa using orthogonal polarization spectral imaging in a patient with bacterialsepsis.
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55
Contributors
Isaac Josh Abecassis MDResident PhysicianDepartment of Neurological SurgeryUniversity of WashingtonSeattle, Washington
Rachel S. Agbeko MD, PhD, FRCPCH, FFICMConsultant in Paediatric Intensive CareDepartment of Paediatric Intensive CareGreat North Children's HospitalThe Newcastle upon Tyne Hospitals NHS Foundation TrustAssociate Clinical LecturerInstitute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUnited Kingdom
P. David Adelson MD, FACS, FAAPDirectorBarrow Neurological Institute at Phoenix Children's HospitalDiane and Bruce Halle Chair of Pediatric NeurosciencesChiefPediatric NeurosurgeryPhoenix Children's HospitalPhoenix, Arizona
Matthew N. Alder PhD, MDInstructor of Pediatrics, University of Cincinnati College of MedicineDivision of Critical Care MedicineCincinnati Children's Hospital Medical CenterChildren's Hospital Research FoundationCincinnati, Ohio
Omar Al Ibrahim MDDirectorCutaneous Laser and Cosmetic SurgeryMohs Micrographic and Reconstructive SurgeryDermatology
56
University of ConnecticutFarmington, Connecticut
Melvin C. Almodovar MDMedical DirectorCardiac Intensive Care UnitDepartment of CardiologyBoston Children's HospitalBoston, Massachusetts
Alexandra R. Aminoff MDPediatric RheumatologyThe Permanente Medical GroupKaiser Permanente Northern CaliforniaOakland, California
Catherine Amlie-LeFond MDDirectorPediatric Vascular Neurology ProgramProfessorSeattle Children's Hospital/University of WashingtonSeattle, Washington
Derek C. Angus MD, MPH, FRCPDistinguished Professor and Mitchell P. Fink Endowed ChairDepartment of Critical Care MedicineProfessor of Critical Care Medicine, Medicine, Health Policy and Management, andClinical and Translational ScienceUniversity of Pittsburgh Schools of the Health SciencesPittsburgh, Pennsylvania
Joan C. Arvedson BS, MS, PhDProgram Coordinator, Feeding and Swallowing ServicesSpeech Pathology and AudiologyChildren's Hospital of WisconsinMilwaukee, Wisconsin
Francois Aspesberro MDPediatric Critical Care MedicineSeattle Children's Hospital/University of WashingtonSeattle, Washington
John E. Baatz PhDProfessorPediatrics - NeonatologyMedical University of South CarolinaCharleston, South Carolina
Harris P. Baden MD
57
Professor & ChiefPediatric Cardiac Critical CareSeattle Children's Hospital/University of WashingtonSeattle, Washington
Srinivasarao Badugu MDAssistant ProfessorDepartment of PediatricsTexas Tech UniversityEl Paso, Texas
Adnan M. Bakar MDAssistant Professor of PediatricsSection HeadPediatric Cardiac Critical CareHofstra Northwell School of MedicinePediatric Critical Care MedicinePediatric CardiologyCohen Children's Medical Center of New YorkNew Hyde Park, New York
Katherine Banker MDClinical Assistant ProfessorPediatricsCritical CareSeattle Children's Hospital/University of WashingtonSeattle, Washington
John L. Bass MDProfessor of PediatricsDirectorPediatric Interventional CatheterizationUniversity of Minnesota/Masonic Children's HospitalMinneapolis, Minnesota
Hülya Bayir MDSafar Center for Resuscitation ResearchDepartment of Critical Care MedicineUniversity of Pittsburgh School of MedicineChildren's Hospital of Pittsburgh of UPMCPittsburgh, Pennsylvania
Pierre Beaulieu MD, PhD, FRCAProfessorDepartments of Medicine and AnesthesiologyFaculty of MedicineUniversité de MontréalMontreal, Quebec, Canada
58
Lance B. Becker MDDirectorCenter for Resuscitation SciencePerelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
Michael J. Bell MDProfessor of Critical Care Medicine, Neurological Surgery, and PediatricsDirectorPediatric Neurocritical CareDirectorPediatric Neurotrauma CenterAssociate DirectorSafar Center for Resuscitation ResearchUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania
M.A. Bender MD, PhDAssociate ProfessorUniversity of WashingtonFred Hutchinson Cancer Research CenterSeattle, Washington
Wade W. Benton PharmDExecutive DirectorMedical AffairsRelypsaRedwood City, California
Robert A. Berg MDRussell Raphaely Endowed ChairDivision ChiefCritical Care MedicineProfessor of AnesthesiologyCritical Care and PediatricsThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
Katherine V. Biagas MD, FCCM, FAAPDirectorPediatric Critical Care Medicine FellowshipAssociate Professor of PediatricsColumbia University Medical CenterNew York, New York
Naomi B. Bishop MDAssistant ProfessorPediatrics
59
DirectorQuality and Patient ImprovementPediatric Critical Care MedicineWeill Cornell MedicineNew York, New York
Julie Blatt MDProfessorPediatric Hematology OncologyUniversity of North CarolinaChapel Hill, North Carolina
Douglas L. Blowey MDAssociate ProfessorPediatrics and PharmacologyPediatric NephrologyUniversity of Missouri—Kansas City/ Children's Mercy HospitalKansas City, Missouri
Jeffrey L. Blumer PhD, MDProfessor of PediatricsUniversity of ToledoCollege of Medicine and Life SciencesToledo, Ohio
Robert H. Bonow MDResident PhysicianDepartment of Neurological SurgeryUniversity of WashingtonSeattle, Washington
Barbara W. Brandom MDNorth American MH Registry of MHAUSAdjunct Professor of Nurse AnesthesiaRetired Professor of AnesthesiologyUniversity of PittsburghPittsburgh, Pennsylvania
Richard J. Brilli MD, FAAP, MCCMDivision of Critical Care MedicineDepartment of PediatricsNationwide Children's HospitalThe Ohio State University College of MedicineColumbus, Ohio
Thomas V. Brogan MDProfessorDepartment of PediatricsSeattle Children's Hospital/University of Washington
60
Seattle, Washington
Ronald A. Bronicki MD, FCCM, FACCCritical Care Medicine and CardiologyTexas Children's Hospital and Baylor College of MedicineHouston, Texas
Samuel R. Browd MD, PhD, FAANS, FAAPProfessorDepartment of Neurological SurgerySeattle Children's Hospital/University of WashingtonSeattle, Washington
Timothy E. Bunchman MDProfessor and Director Pediatric NephrologyChildren's Hospital of RichmondVirginia Commonwealth University School of MedicineRichmond, Virginia
Jeffrey P. Burns MD, MPHChief and Shapiro Chair of Critical Care MedicineBoston Children's HospitalProfessor of AnesthesiaHarvard Medical SchoolBoston, Massachusetts
Derya Caglar MDAssistant ProfessorPediatricsAttending PhysicianPediatric Emergency MedicineSeattle Children's Hospital/University of WashingtonSeattle, Washington
Sally Campbell BSHaematology RegistrarClinical HaematologyRoyal Children's HospitalMelbourne, Victoria, Australia
Joseph A. Carcillo MDAssociate Professor of Critical Care Medicine and PediatricsChildren's Hospital of Pittsburgh of UPMCUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania
Hector Carrillo-Lopez MDProfessor of Pediatric Critical Care and PediatricsHospital Infantil de Mexico Federico Gomez
61
Universidad Nacional Autonoma de MexicoMexico City, Mexico
Katherine Cashen DOPediatric IntensivistChildren's Hospital of MichiganAssistant ProfessorDivision of Critical Care MedicineDepartment of PediatricsWayne State University School of MedicineDetroit, Michigan
Antonio Cassara MDVisiting Assistant ProfessorUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania
John R. Charpie MD, PhDProfessor and Division Director, Pediatric CardiologyPediatrics and Communicable DiseasesUniversity of Michigan Medical SchoolAnn Arbor, Michigan
Adrian Chavez MDDirectorPediatric Intensive CareHospital Infantil de Mexico Federico GomezHead Professor of Pediatric Critical Care and PediatricsFacultad de MedicinaUniversidad Nacional Autonoma de MexicoMexico City, Mexico
Robert H. Chun MDAssociate ProfessorDepartment of OtolaryngologyDivision of Pediatric OtolaryngologyMedical College of WisconsinMilwaukee, Wisconsin
Jonna Derbenwick Clark MD, MAAssistant ProfessorPediatrics, Critical Care MedicineAffiliate FacultyTreuman Katz Center for Pediatric BioethicsDepartment of PediatricsSeattle Children's Hospital/University of WashingtonSeattle, Washington
Robert S.B. Clark MD
62
Professor and ChiefPediatric Critical Care MedicineMedical DirectorBrain Care InstituteChildren's Hospital of Pittsburgh of UPMCAssociate DirectorSafar Center for Resuscitation ResearchUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania
Katherine C. Clement MDAssistant Professor of PediatricsUNC School of MedicineChapel Hill, North Carolina
Thomas Conlon MDDirector of Pediatric Critical Care UltrasoundAssistant ProfessorDepartment of Anesthesiology and Critical Care MedicineThe Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of MedicinePhiladelphia, Pennsylvania
Edward E. Conway Jr., MD, MSChairman and Pediatrician-in-ChiefMilton and Bernice Stern Department of PediatricsBeth Israel Medical CenterProfessor of PediatricsIcahn School of Medicine at Mount SinaiNew York, New York
Craig M. Coopersmith MDProfessor of SurgeryDepartment of SurgeryEmory University School of MedicineAtlanta, Georgia
Seth J. Corey MEProfessor in Pediatrics and Cell and Molecular BiologyNorthwestern University Feinberg School of MedicineEvanston, Illinois
Peter N. Cox MDProfessorCritical Care MedicineHospital for Sick ChildrenToronto, Ontario, Canada
Martha A.Q. Curley RN, PhD, FAANEllen and Robert Kapito Professor in Nursing Science
63
School of Nursing/Anesthesia and Critical Care MedicineUniversity of PennsylvaniaNurse ScientistCritical Care and Cardiovascular ProgramBoston Children's HospitalBoston, Massachusetts
Marek Czosnyka PhDProfessor of Clinical NeuroscienceUniversity of Cambridge Clinical SchoolDepartment of NeurosurgeryAddenbrooke's HospitalCambridge, United Kingdom
Heidi J. Dalton MD, MCCMProfessor of PediatricsVirginia Commonwealth UniversityClinical Professor of SurgeryGeorge Washington UniversityDirectorAdult and Pediatric ECLSINOVA Fairfax Medical CenterFalls Church, Virginia
Mihaela Damian MD, MPHClinical Assistant ProfessorDepartment of PediatricsStanford UniversityPalo Alto, California
Peter J. Davis MDDr. Joseph H. Marcy Endowed Chair in Pediatric AnesthesiaUniversity of Pittsburgh School of MedicineAnesthesiologist-in-ChiefChildren's Hospital of Pittsburgh of UPMCDepartment of AnesthesiaPittsburgh, Pennsylvania
Nicolas de Prost MD, PhDService de Réanimation MédicaleHôpital Henri MondorAssistance PubliqueGroupe de Recherche Clinique CARMASUniversité Paris Est CréteilCréteil, France
Clifford S. Deutschman MDProfessor of Anesthesiology and Critical CareDirector
64
Sepsis Research ProgramPerelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
Cameron Dezfulian MDSafar Center for Resuscitation ResearchDepartment of Critical Care MedicineUniversity of Pittsburgh School of MedicineChildren's Hospital of Pittsburgh of UPMCPittsburgh, Pennsylvania
Douglas S. Diekema MD, MPHProfessor of Pediatrics and BioethicsTreuman Katz Center for Pediatric BioethicsSeattle Children's Hospital/University of WashingtonSeattle, Washington
Allan Doctor MDProfessor of Pediatrics and BiochemistryWashington University School of MedicineSt. Louis, Missouri
Meaghan Doherty MDPediatric Cardiology FellowCardiologyChildren's Hospital of PittsburghPittsburgh, Pennsylvania
Molly V. Dorfman MD, PhDPediatric Critical CareValley Children's HospitalMadera, California
John J. Downes MDDepartment of Anesthesiology and Critical Care MedicineThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
Didier Dreyfuss MDProfessor of MedicineHospital of ParisParis, France
Christine Duncan MDAssistant ProfessorPediatric Hematology OncologyDana-Farber Cancer InstituteBoston, Massachusetts
65
Phylicia D. Dupree MDResident PhysicianGeneral SurgeryUniversity of CincinnatiCincinnati, Ohio
Howard Eigen MDProfessor of Pediatrics (ret.)Indiana University School of MedicinePresidentInspire FoundationIndianapolis, Indiana
Nahed El-Hassan MDAssociate Professor of PediatricsUniversity of Arkansas for Medical SciencesArkansas Children's HospitalLittle Rock, Arkansas
Carl O. Eriksson MDAssistant ProfessorPediatric Critical CareDepartment of PediatricsOregon Health and Science UniversityPortland, Oregon
Kate Felmet MDAssistant ProfessorDepartments of Critical Care Medicine and PediatricsUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania
Jeffrey R. Fineman MDProfessor of PediatricsUniversity of California, San FranciscoSan Francisco, California
Ericka L. Fink MD, MSAssociate ProfessorSafar Center for Resuscitation ResearchDepartment of Critical Care MedicineUniversity of Pittsburgh School of MedicineChildren's Hospital of Pittsburgh of UPMCPittsburgh, Pennsylvania
Frank A. Fish MDProfessorPediatricsVanderbilt Medical Center
66
Nashville, Tennessee
Tamara N. Fitzgerald MD, PhDAssistant ProfessorDepartment of SurgeryTexas Tech University – Paul L. Foster School of MedicineEl Paso, Texas
Joseph T. Flynn MDProfessor of PediatricsChief - Division of NephrologySeattle Children's Hospital/University of WashingtonSeattle, Washington
J. Julio Pérez Fontán MDRobert L. Moore Chair in PediatricsProfessor and Chairman, Department of PediatricsUniversity of Texas Southwestern Medical CenterPhysician-in-Chief, Children's Medical Center, DallasDallas, Texas
Michael J. Forbes MD, FAAPDirectorClinical Research and Outcomes AnalysisPediatric Intensive Care UnitFellowAmerican Academy of Pediatrics Society of Critical Care MedicineAkron, Ohio
Joseph M. Forbess MDDirectorCardiothoracic SurgeryCo-DirectorHeart CenterChildren's Health, DallasProfessor of Thoracic and Cardiovascular SurgeryPogue Distinguished Chair in Pediatric Cardiac Surgery ResearchUniversity of Texas Southwestern Medical CenterDallas, Texas
Deborah E. Franzon MDClinical Professor of PediatricsDivision of Critical Care MedicineUniversity of California, San FranciscoSan Francisco, California
W. Joshua Frazier MDDivision of Critical Care MedicineDepartment of Pediatrics
67
Nationwide Children's HospitalThe Ohio State University College of MedicineColumbus, Ohio
F. Jay Fricker MDUF Health Congenital Heart CenterGainesville, Florida
Bradley P. Fuhrman MD, FCCMProfessor and ChairDepartment of PediatricsTexas Tech University – Paul L. Foster School of MedicinePhysician-in-ChiefEl Paso Children's HospitalEl Paso, Texas
Xiomara Garcia-Casal MDAssociate Professor of PediatricsUniversity of Arkansas for Medical SciencesArkansas Children's HospitalLittle Rock, Arkansas
Rebecca Gardner MDAssistant ProfessorPediatricsUniversity of WashingtonSeattle, Washington
Eli Gilad MDPediatric Critical CareAlberta Children's Hospital and the University of CalgaryCalgary, Alberta, Canada
Richard M. Ginther Jr., CCP, FPPFaculty AssociatePediatric PerfusionistPediatric Cardiothoracic SurgeryUniversity of Texas Southwestern Medical CenterChildren's Health DallasDallas, Texas
Nicole Glaser MDProfessorPediatric EndocrinologyUC Davis Children's HospitalSacramento, California
Denise M. Goodman MD, MSAttending Physician
68
Division of Critical Care MedicineMedical DirectorCase Management and Care Coordination (Physician Advisor)Ann and Robert H. Lurie Children's Hospital of ChicagoProfessorNorthwestern University Feinberg School of MedicineChicago, Illinois
Ana Lía Graciano MD, FAAP, FCCMDepartment of PediatricsCritical Care MedicineMedical DirectorPediatric Cardiac Intensive CareUniversity of Maryland School of MedicineBaltimore, Maryland
Kristin C. Greathouse PhD(c), MS, BSN, CPNP-ACThe Heart CenterNationwide Children's HospitalColumbus, Ohio
Bruce M. Greenwald MD, FAAP, FCCMProfessor of Clinical PediatricsExecutive Vice-ChairmanDepartment of PediatricsChiefDivision of Pediatric Critical Care MedicineWeill Cornell MedicineNew York, New York
Björn Gunnarsson MDDepartment of ResearchNorwegian Air Ambulance FoundationDrøbak, NorwaySAR HelicopterØrland Main Air Station, Norway
Punkaj Gupta MBBSAssociate Professor of PediatricsUniversity of Arkansas for Medical SciencesArkansas Children's HospitalLittle Rock, Arkansas
Mark W. Hall MD, FCCMAssociate Professor of PediatricsChiefDivision of Critical Care MedicineNationwide Children's HospitalThe Ohio State University
69
Columbus, Ohio
Yong Y. Han MDPhysical ScientistNOAA/NESDISCenter for Satellite Application and ResearchCollege Park, Maryland
Cary O. Harding MDProfessorMolecular and Medical GeneticsOregon Health and Science UniversityPortland, Oregon
Mary E. Hartman MD, MPH, FRCPAssistant Professor of PediatricsPediatric Critical Care MedicineDepartment of PediatricsWashington University School of MedicineSt. Louis, Missouri
Silvia M. Hartmann MDAssistant ProfessorPediatric Critical Care MedicineSeattle Children's Hospital/University of Washington School of MedicineSeattle, Washington
Christopher M.B. Heard MB, ChB, FRCAClinical Professor of Anesthesiology PediatricsPediatric and Community DentistryThe State University of New York at BuffaloBuffalo, New York
Lynn J. Hernan MDAssociate ProfessorPediatricsTexas Tech University—Paul L. Foster School of MedicineEl Paso, Texas
Mark J. Heulitt MD, FCCMMedical Director of Pediatric Intensive Care UnitSpence and Becky Wilson Baptist Children's HospitalMemphis, Tennessee
Julien I. Hoffman MDProfessor (Emeritus)PediatricsUniversity of California, San FranciscoSan Francisco, California
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Simon Horslen MDProfessorPediatricsUniversity of Washington School of MedicineSeattle, Washington
Agnes I. Hunyady MDAttending AnesthesiologistSeattle Children's Hospital/University of WashingtonAssistant ProfessorUniversity of Washington School of MedicineSeattle, Washington
Laura Marie Ibsen MDProfessorPediatrics and AnesthesiologyOregon Health and Science UniversityPortland, Oregon
Hanneke IJsselstijn MD, PhDPediatric Surgery and Intensive CareErasmus MC - Sophia Children's HospitalRotterdam, The Netherlands
Andrew Inglis Jr., MDAssociate ProfessorDepartment of OtolaryngologySeattle Children's Hospital/University of WashingtonSeattle, Washington
Gretchen A. Linggi Irby PharmDPharmacistSeattle, Washington
Olivia K. Irby MDAssistant Professor of PediatricsUniversity of Arkansas for Medical SciencesArkansas Children's HospitalLittle Rock, Arkansas
Gisele E. Ishak MDAssociate ProfessorDepartment of RadiologyUniversity of WashingtonSeattle Children's Hospital/University of WashingtonSeattle, Washington
Travis C. Jackson PhDResearch Assistant Professor
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Department of Critical Care MedicineAssociate Director of Cell SignalingSafar Center for Resuscitation ResearchPittsburgh, Pennsylvania
Susan Jacob PharmDInvestigational Drug ServiceSeattle Children's Hospital/University of WashingtonSeattle, Washington
Shelina M. Jamal MDClinical Assistant ProfessorPediatric Critical CareSeattle Children's Hospital/University of WashingtonSeattle, Washington
David Jardine MDAssociate ProfessorDepartment of OtolaryngologySeattle Children's Hospital/University of Washington School of MedicineSeattle, Washington
Alberto Jarillo MDHeadRespiratory Therapy ServiceAssociate Professor of PediatricCritical Care and PediatricsHospital Infantil de Mexico Federico GomezMexico City, Mexico
Alison M. Jeziorski MD, MBAAssistant ProfessorDepartment of Anesthesia and Perioperative MedicineMedical University of South CarolinaCharleston, South Carolina
Umesh Joashi MDConsultant Paediatric IntensivistLeeds Teaching Hospitals NHS TrustLeeds, United Kingdom
Prashant Joshi MDAssociate ProfessorPediatricsUniversity of Nebraska Medical CenterOmaha, Nebraska
Richard J. Kagan MDProfessor
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SurgeryUniversity of Cincinnati College of MedicineCincinnati, Ohio
Prince J. Kannankeril MDAssociate ProfessorPediatricsVanderbilt Children's HospitalNashville, Tennessee
Robert K. Kanter MD †Adjunct Senior Research ScientistNational Center for Disaster PreparednessColumbia UniversityNew York, New York
Oliver Karam MDAssociate ProfessorPediatric Intensive Care UnitGeneva University HospitalGeneva, Switzerland
Cristin D.W. Kaspar MDPediatric Nephrology FellowChildren's Hospital of RichmondVirginia Commonwealth University School of MedicineRichmond, Virginia
Robinder G. Khemani MD, MsCIAssociate Director of ResearchDepartment of Anesthesiology and Critical CareCritical Care MedicineChildren's Hospital Los AngelesAssociate Professor of PediatricsUniversity of Southern California Keck School of MedicineLos Angeles, California
Mary A. King MDProfessor of Genome Sciences and of MedicineUniversity of WashingtonSeattle, Washington
Christa C. Jefferis Kirk PharmDClinical Staff PharmacistCritical CareSeattle Children's HospitalSeattle, Washington
Niranjan (Tex) Kissoon MD
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Professor in Acute and Critical Care—Global Child HealthPediatrics and Surgery (EM)The University of British Columbia and BC Children's HospitalVancouver, British Columbia, Canada
Patrick M. Kochanek MD, MCCMAke N. Grenvik Professor and Vice Chair of Critical Care MedicineProfessor of Anesthesiology, Pediatrics and Bioengineering, and Clinical andTranslational ScienceDirectorSafar Center for Resuscitation ResearchUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania
Keith C. Kocis MD, MSDirectorPediatric Cardiac Intensive CareInterim DirectorPediatric Critical Care MedicineSidra Medical and Research CenterDoha, Qatar
Samuel A. Kocoshis MDProfessorPediatricsUniversity of Cincinnati College of MedicineCincinnati, Ohio
Tsingyi Koh PharmD, BCPSPrincipal Clinical Pharmacist Pediatrics/Solid Organ TransplantDepartment of PharmacyNational University HospitalSingapore
Ada Kong PharmDResearch PharmacistSeattle Children's Hospital/University of WashingtonSeattle, Washington
Ildiko H. Koves MD, FRACPAssociate ProfessorEndocrinology and DiabetesSeattle Children's Hospital/University of WashingtonSeattle, Washington
Thomas J. Kulik MDSenior Associate in CardiologyCardiologyBoston Children's Hospital
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Boston, Massachusetts
Vasanth H. Kumar MDAssociate ProfessorDepartment of PediatricsDirectorNeonatal-Perinatal Medicine Fellowship ProgramThe State University of New York at BuffaloWomen and Children's Hospital of BuffaloBuffalo, New York
Jacques Lacroix MDProfessorDivision of Pediatric Intensive CareDepartment of PediatricsSainte-Justine HospitalUniversité de MontréalMontreal, Quebec, Canada
Satyan Lakshminrusimha MDProfessor of PediatricsChiefDivision of NeonatologyWomen and Children's Hospital of BuffaloDirectorCenter for Developmental BiologyThe State University of New York at BuffaloBuffalo, New York
Thomas J. Lee MDMajorUnited States Air ForceSan Antonio, Texas
Marie Leiner PhDResearch Associate ProfessorPediatricsTexas Tech University Health Sciences CenterEl Paso, Texas
Daniel L. Levin MDProfessor EmeritusDepartments of Pediatrics and AnesthesiaChildren's Hospital at DartmouthGeisel School of MedicineLebanon, New Hampshire
Mithya Lewis-Newby MD, MPHAssociate Professor
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